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Paskins Z, Babatunde O, Sturrock A, Toh LS, Horne R, Maidment I. Supporting patients to get the best from their osteoporosis treatment: a rapid realist review of what works, for whom, and in what circumstance. Osteoporos Int 2022; 33:2245-2257. [PMID: 35688897 PMCID: PMC9568441 DOI: 10.1007/s00198-022-06453-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 05/28/2022] [Indexed: 11/23/2022]
Abstract
Systematic reviews that examine effectiveness of interventions to improve medicines optimisation do not explain how or why they work. This realist review identified that interventions which effectively optimise medicines use in osteoporosis include opportunities to address patients' perceptions of illness and treatment and/or support primary care clinician decision making. INTRODUCTION In people with osteoporosis, adherence to medicines is poorer than other diseases and patients report follow-up is lacking, and multiple unmet information needs. We conducted a rapid realist review to understand what contextual conditions and mechanisms enable interventions to support osteoporosis medication optimisation. METHODS A primary search identified observational or interventional studies which aimed to improve medicines adherence or optimisation; a supplementary second search identified research of any design to gain additional insights on emerging findings. Extracted data was interrogated for patterns of context-mechanism-outcome configurations, further discussed in team meetings, informed by background literature and the Practicalities and Perception Approach as an underpinning conceptual framework. RESULTS We identified 5 contextual timepoints for the person with osteoporosis (identifying a problem; starting medicine; continuing medicine) and the practitioner and healthcare system (making a diagnosis and giving a treatment recommendation; reviewing medicine). Interventions which support patient-informed decision making appear to influence long-term commitment to treatment. Supporting patients' practical ability to adhere (e.g. by lowering treatment burden and issuing reminders) only appears to be helpful, when combined with other approaches to address patient beliefs and concerns. However, few studies explicitly addressed patients' perceptions of illness and treatment. Supporting primary care clinician decision making and integration of primary and secondary care services also appears to be important, in improving rates of treatment initiation and adherence. CONCLUSIONS We identified a need for further research to identify a sustainable, integrated, patient-centred, and cost- and clinically effective model of long-term care for people with osteoporosis.
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Affiliation(s)
- Z Paskins
- School of Medicine, Keele University, Keele, UK.
- Haywood Academic Rheumatology Centre, Stoke-on-Trent, Staffordshire, UK.
| | - O Babatunde
- School of Medicine, Keele University, Keele, UK
| | - A Sturrock
- Department of Nursing, Midwifery and Health, Northumbria University, Newcastle upon Tyne, UK
| | - L S Toh
- Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, Nottingham, UK
| | - R Horne
- Centre for Behavioural Medicine, UCL School of Pharmacy, University College London, London, UK
| | - I Maidment
- Clinical Pharmacy, Aston University, Birmingham, UK
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Liu CS, Feasel AL, Kline GA, Billington EO. Pharmacotherapy decisions among postmenopausal women attending a group medical consultation or a one-on-one specialist consultation at an osteoporosis center: an observational cohort study. Osteoporos Int 2021; 32:1421-1427. [PMID: 33462652 DOI: 10.1007/s00198-021-05823-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 01/04/2021] [Indexed: 12/21/2022]
Abstract
UNLABELLED Group medical visits for osteoporosis can improve access to care while being highly accepted by patients. In this study, a similar proportion of women planned to initiate pharmacotherapy after attending a group or traditional one-on-one osteoporosis consultation, indicating that the group consultation model does not produce unexpected treatment decisions. INTRODUCTION Group medical consultations for osteoporosis are time-efficient and highly accepted by patients, but effects on treatment decisions are unknown. We aimed to compare women's decisions to initiate or decline osteoporosis pharmacotherapy after attending either a group or transitional one-on-one osteoporosis consultation. METHODS In this observational study, we prospectively evaluated postmenopausal women referred to an osteoporosis clinic who attended a group medical visit and compared their decisions regarding pharmacologic osteoporosis treatment with retrospective data from a cohort of women who attended a traditional consultation. Both consultation types involved interaction with a specialist physician, individualized fracture risk estimation (using FRAX®), and education regarding fracture consequences and available osteoporosis medications. Both forms of consultation emphasized shared decision-making; however, group consultation attendees did not receive personalized treatment recommendations from the physician. RESULTS We reviewed the records of 125 women (median age 63 years) who attended a group consultation and 83 women (median age 64 years) who attended a traditional consultation between 2016 and 2019. Twenty-four (19%) of the group cohort and 16 (19%) of the traditional cohort were at high 10-year risk of major osteoporotic fracture (FRAX® ≥ 20.0%). A similar proportion planned to initiate pharmacologic therapy after the group and traditional consultations (23% vs 16%, p = 0.22); these proportions were comparable among women at high risk (42% vs 50%, p = 0.75) and moderate risk (19% vs 15%, p = 0.77), but a higher proportion of low-risk women planned to initiate therapy after the group consultation (18% vs 0%, p = 0.009). CONCLUSION Patient decisions to initiate pharmacologic treatment made during a group visit are similar to those made during traditional one-on-one consultation. The group consultation model represents an alternative to one-on-one assessment for delivering osteoporosis consultative services.
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Affiliation(s)
- C S Liu
- Undergraduate Medical Education, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - A L Feasel
- Dr. David Hanley Osteoporosis Centre, Alberta Health Services, Richmond Road Diagnostic & Treatment Centre, Calgary, Alberta, Canada
| | - G A Kline
- Dr. David Hanley Osteoporosis Centre, Alberta Health Services, Richmond Road Diagnostic & Treatment Centre, Calgary, Alberta, Canada
- Division of Endocrinology & Metabolism, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - E O Billington
- Dr. David Hanley Osteoporosis Centre, Alberta Health Services, Richmond Road Diagnostic & Treatment Centre, Calgary, Alberta, Canada.
- Division of Endocrinology & Metabolism, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
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Cornelissen D, de Kunder S, Si L, Reginster JY, Evers S, Boonen A, Hiligsmann M. Interventions to improve adherence to anti-osteoporosis medications: an updated systematic review. Osteoporos Int 2020; 31:1645-1669. [PMID: 32358684 PMCID: PMC7423788 DOI: 10.1007/s00198-020-05378-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 03/04/2020] [Indexed: 01/25/2023]
Abstract
UNLABELLED An earlier systematic review on interventions to improve adherence and persistence was updated. Fifteen studies investigating the effectiveness of patient education, drug regimen, monitoring and supervision, and interdisciplinary collaboration as a single or multi-component intervention were appraised. Multicomponent interventions with active patient involvement were more effective. INTRODUCTION This study was conducted to update a systematic literature review on interventions to improve adherence to anti-osteoporosis medications. METHODS A systematic literature review was carried out in Medline (using PubMed), Embase (using Ovid), Cochrane Library, Current Controlled Trials, ClinicalTrials.gov , NHS Centre for Review and Dissemination, CINHAL, and PsycINFO to search for original studies that assessed interventions to improve adherence (comprising initiation, implementation, and discontinuation) and persistence to anti-osteoporosis medications among patients with osteoporosis, published between July 2012 and December 2018. Quality of included studies was assessed. RESULTS Of 585 studies initially identified, 15 studies fulfilled the inclusion criteria of which 12 were randomized controlled trials. Interventions were classified as (1) patient education (n = 9), (2) drug regimen (n = 3), (3) monitoring and supervision (n = 2), and (4) interdisciplinary collaboration (n = 1). In most subtypes of interventions, mixed results on adherence (and persistence) were found. Multicomponent interventions based on patient education and counseling were the most effective interventions when aiming to increase adherence and/or persistence to osteoporosis medications. CONCLUSION This updated review suggests that patient education, monitoring and supervision, change in drug regimen, and interdisciplinary collaboration have mixed results on medication adherence and persistence, with more positive effects for multicomponent interventions with active patient involvement. Compared with the previous review, a shift towards more patient involvement, counseling and shared decision-making, was seen, suggesting that individualized solutions, based on collaboration between the patient and the healthcare provider, are needed to improve adherence and persistence to osteoporosis medications.
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Affiliation(s)
- D Cornelissen
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, P.O. Box 616, Room 0.038, 6200, Maastricht, MD, Netherlands.
| | - S de Kunder
- Department of Primary and Community Care, Center for Family Medicine, Geriatric Care and Public Health, Radboud University Medical Center, Nijmegen, Netherlands
| | - L Si
- The George Institute for Global Health, UNSW Sydney, Kensington, Australia
| | - J-Y Reginster
- WHO Collaborating Center for Public Health Aspects of Musculoskeletal Health and Ageing, Department of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
- Biomarkers of Chronic Diseases, Biochemistry Department, College of Science, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - S Evers
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, P.O. Box 616, Room 0.038, 6200, Maastricht, MD, Netherlands
- Centre for economic evaluation, Trimbos Institute, Netherlands Institute of Mental Health and Addiction, Utrecht, Netherlands
| | - A Boonen
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, P.O. Box 616, Room 0.038, 6200, Maastricht, MD, Netherlands
- Department of Internal Medicine, Rheumatology, Maastricht University Medical Centre and CAPHRI, Maastricht University, Maastricht, Netherlands
| | - M Hiligsmann
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, P.O. Box 616, Room 0.038, 6200, Maastricht, MD, Netherlands
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Billington EO, Feasel AL, Kline GA. At Odds About the Odds: Women's Choices to Accept Osteoporosis Medications Do Not Closely Agree with Physician-Set Treatment Thresholds. J Gen Intern Med 2020; 35:276-282. [PMID: 31625042 PMCID: PMC6957614 DOI: 10.1007/s11606-019-05384-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 07/22/2019] [Accepted: 09/04/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Osteoporosis guidelines recommend pharmacologic therapy based on 10-year risk of major osteoporotic fracture (MOF) and hip fracture, which may fail to account for patient-specific experiences and values. OBJECTIVE We aimed to determine whether patient decisions to initiate osteoporosis medication agree with guideline-recommended intervention thresholds. DESIGN AND PARTICIPANTS This prospective cohort study included women aged ≥ 45 with age-associated osteoporosis who attended a group osteoporosis self-management consultation at a tertiary osteoporosis center. INTERVENTION A group osteoporosis self-management consultation, during which participants received osteoporosis education and then calculated1 their 10-year MOF and hip fracture risk using FRAX and2 their predicted absolute fracture risk with therapy (assuming 40% relative reduction). Participants then made autonomous decisions regarding treatment initiation. MAIN MEASURES We evaluated agreement between treatment decisions and physician-set intervention thresholds (10-year MOF risk ≥ 20%, hip fracture risk ≥ 3%). KEY RESULTS Among 85 women (median [IQR] age 62 [58-67]), 27% accepted treatment (median [IQR] MOF risk, 15.1% [9.9-22.0]; hip fracture risk, 3.3% [1.3-5.3]), 46% declined (MOF risk, 9.5% [6.5-11.6]; hip fracture risk, 1.8% [0.6-2.3]), and 27% remained undecided (MOF risk, 14.0% [9.8-20.2]; hip fracture risk, 4.4% [1.7-4.9]). There was wide overlap in fracture risk between treatment acceptors and non-acceptors. Odds of accepting treatment were higher in women with prior fragility fracture (50% accepted; OR, 5.3; 95% CI, 1.9-15.2; p = 0.0015) and with hip fracture risk ≥ 3% (32% accepted; OR, 3.6; 95% CI, 1.4-9.2; p = 0.012), but not MOF risk ≥ 20% (47% accepted; OR, 3.0; 95% CI, 1.0-8.5; p = 0.105). CONCLUSIONS Informed decisions to start osteoporosis treatment are highly personal and not easily predicted using fracture risk. Guideline-recommended intervention thresholds may not permit sufficient consideration of patient preferences.
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Affiliation(s)
- Emma O Billington
- Division of Endocrinology & Metabolism, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada. .,Dr. David Hanley Osteoporosis Centre, Alberta Health Services, Calgary, Alberta, Canada.
| | - A Lynn Feasel
- Dr. David Hanley Osteoporosis Centre, Alberta Health Services, Calgary, Alberta, Canada
| | - Gregory A Kline
- Division of Endocrinology & Metabolism, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Dr. David Hanley Osteoporosis Centre, Alberta Health Services, Calgary, Alberta, Canada
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Abstract
PURPOSE OF REVIEW The aims of this review are to summarize current performance for osteoporosis quality measures used by Centers for Medicare and Medicaid (CMS) for pay-for-performance programs and to describe recent quality improvement strategies around these measures. RECENT FINDINGS Healthcare Effectiveness Data and Information (HEDIS) quality measures for the managed care population indicate gradual improvement in osteoporosis screening, osteoporosis identification and treatment following fragility fracture, and documentation of fall risk assessment and plan of care between 2006 and 2016. However, population-based studies suggest achievement for these process measures is lower where reporting is not mandated. Performance gaps remain, particularly for post-fracture care. Elderly patients with increased comorbidity are especially vulnerable to fractures, yet underperformance is documented in this population. Gender and racial disparities also exist. As has been shown for other areas of health care, education alone has a limited role as a quality improvement intervention. Multifactorial and systems-based interventions seem to be most successful in leading to measurable change for osteoporosis care and fall prevention. Despite increasing recognition of evidence-based quality measures for osteoporosis and incentives to improve upon performance for these measures, persistent gaps in care exist that will require further investigation into sustainable and value-adding quality improvement interventions.
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Affiliation(s)
- S French
- Division of Rheumatology, Department of Medicine, University of California, 4150 Clement St, Rm 111R, San Francisco, CA, 94121, USA
| | - S Choden
- Division of Rheumatology, Department of Medicine, University of California, 4150 Clement St, Rm 111R, San Francisco, CA, 94121, USA
| | - Gabriela Schmajuk
- Division of Rheumatology, Department of Medicine, University of California, 4150 Clement St, Rm 111R, San Francisco, CA, 94121, USA.
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA, USA.
- Rheumatology Section, Medical Service, San Francisco VA Hospital, San Francisco, CA, USA.
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Abstract
PURPOSE OF REVIEW In this review, we present the application of pragmatic clinical trials for evaluating interventions in osteoporosis, and we discuss methodological considerations for designing and conducting a pragmatic clinical trial compared with a classical randomized clinical trial. RECENT FINDINGS Pragmatic clinical trials are a popular study design testing effectiveness of health interventions and are intended to address the limitations associated with traditional explanatory randomized clinical trials testing efficacy of interventions. To date, only few pragmatic clinical trials have been conducted in osteoporosis. Pragmatic clinical trials are conducted under routine clinical practice setting and are intended to inform policy makers and clinical decisions. Osteoporosis is a chronic disease well-suited to this particular study design given the existence of a clear and specific natural endpoint, namely fracture occurrence, and the availability of several treatments to prevent fractures.
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Affiliation(s)
- Giovanni Adami
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, 510 20th Street South, Faculty Office Tower 820D, Birmingham, AL, 35294, USA
- Rheumatology Unit, University of Verona, Pz Scuro 10, 37135, Verona, Italy
| | - Kenneth G Saag
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, 510 20th Street South, Faculty Office Tower 820D, Birmingham, AL, 35294, USA.
| | - Maria I Danila
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, 510 20th Street South, Faculty Office Tower 820D, Birmingham, AL, 35294, USA
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Edmonds S, Lou Y, Robinson B, Cram P, Roblin DW, Wright NC, Saag K, Wolinsky FD. Characteristics of older adults using patient web portals to view their DXA results. BMC Med Inform Decis Mak 2019; 19:187. [PMID: 31533717 PMCID: PMC6751667 DOI: 10.1186/s12911-019-0904-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 08/27/2019] [Indexed: 11/10/2022] Open
Abstract
Background Sharing test results with patients via patient web portals is a new trend in healthcare. No research has been done examining patient web portal use with bone density test results. The objective of our study was to identify patient characteristics associated with the use of patient web portals to view their bone density test results. Methods A secondary analysis of data from a pragmatic randomized controlled trial of 7749 participants ≥50 years old that had presented for a dual energy X-ray absorptiometry (DXA) bone density test. Patients were interviewed at enrollment and 12 weeks later. Multivariable logistic regression identified patient characteristics that differentiated those who used the web portal from those who did not. Results Our sample included 4669 patients at the two (University of Iowa [UI], and Kaiser Permanente of Georgia [KPGA]) clinical sites that had patient web portals. Of these patients, 3399 (72.8%) reported knowing their test results 12 weeks post-DXA, with 649 (13.9%) reporting that they viewed their DXA results using the web portal. Web portal users were more likely to be from UI than KPGA, and were younger, more educated, had higher health literacy, had osteopenia, and had the same sex as their referring physician (all p < 0.05). Conclusion Only 19.1% of the 3399 patients who knew their DXA results used the available patient web portals to find out about them. Web portal users differed from non-users on several characteristics. This suggests that simply making patient web portals available for use may not be sufficient to appreciably enhance patient awareness of their test results. Based on these findings, a better understanding of the reasons why older, less educated, and less activated patients do not access their test results through patient web portals is needed.
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Affiliation(s)
- Stephanie Edmonds
- Carver College of Medicine, Department of Internal Medicine, University of Iowa, 200 Newton Rd. 5231 WL, Iowa City, IA, 52242, USA. .,CADRE, Iowa City VA Health System, Iowa City, IA, USA.
| | - Yiyue Lou
- College of Public Health, Department of Biostatistics, University of Iowa, Iowa City, IA, USA
| | - Brandi Robinson
- Kaiser Permanente, Center for Clinical and Outcomes Research, Atlanta, GA, USA
| | - Peter Cram
- College of Medicine, Department of Internal Medicine, University of Toronto, Toronto, Canada.,University of Toronto Health Network, Toronto, Canada
| | | | - Nicole C Wright
- School of Public Health, Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, UK
| | - Kenneth Saag
- School of Medicine, Department of Rheumatology, University of Alabama at Birmingham, Birmingham, AL, UK
| | - Fredric D Wolinsky
- Carver College of Medicine, Department of Internal Medicine, University of Iowa, 200 Newton Rd. 5231 WL, Iowa City, IA, 52242, USA.,College of Public Health, Department of Health Management and Policy, University of Iowa, Iowa City, IA, USA.,College of Nursing, University of Iowa, Iowa City, IA, USA
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Solimeo SL, Nguyen VTT, Edmonds SW, Lou Y, Roblin DW, Saag KG, Cram P, Wolinsky FD. Sex differences in osteoporosis self-efficacy among community-residing older adults presenting for DXA. Osteoporos Int 2019; 30:1033-1041. [PMID: 30701343 PMCID: PMC7720864 DOI: 10.1007/s00198-019-04854-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 01/13/2019] [Indexed: 11/28/2022]
Abstract
The Osteoporosis Self Efficacy Scale was determined to equivalently measure calcium and exercise beliefs in both sexes. Despite data illustrating men's and women's similar self-efficacy, gender differences in clinical predictors of self-efficacy imply that efforts to improve care must account for more than self-efficacy. INTRODUCTION To understand the extent to which the Osteoporosis Self Efficacy (OSE) Scale is reliable for both men and women. A secondary objective was to evaluate sex differences in OSE. METHODS For this cross-sectional study, we analyzed data collected as part of the Patient Activation after DXA Result Notification (PAADRN) pragmatic trial which enrolled 7749 community-residing adults aged 50 and older reporting for bone densitometry. We used univariable methods, item analysis, exploratory and confirmatory factor analyses, and linear regression to evaluate sex differences in OSE responses and measurement. RESULTS In this sample, the confirmatory factor analysis model for OSE both overall and within groups indicated a poor fit. The sex differences in the measurement model, however, were minor and reflected configural invariance (i.e., constructs were measuring the same things in both men and women), confirming that the OSE was measuring the same constructs in men and women. Men overall had higher exercise self-efficacy and women higher calcium self-efficacy. Overall, education, hip fracture, and self-reported health status predicted exercise self-efficacy whereas prior DXA, self-reported osteoporosis, and history of pharmacotherapy use did not. Predictors of calcium self-efficacy differed by gender. CONCLUSION The OSE can be used to measure calcium and exercise self-efficacy in all older adults. However, gender differences in clinical predictors of self-efficacy and the lack of an association of prior DXA with self-efficacy imply that interventions to improve self-efficacy may be insufficient to drive significant improvement in rates of osteoporosis evaluation and treatment. TRIAL REGISTRATION Patient Activation after DXA Result Notification (PAADRN), NCT01507662, https://clinicaltrials.gov/ct2/show/NCT01507662.
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Affiliation(s)
- S L Solimeo
- Division of General Internal Medicine, Department of Internal Medicine, College of Medicine, University of Iowa Carver, Iowa City, IA, USA.
- Department of Veterans Affairs, CADRE, Iowa City VA HCS, Iowa City, IA, USA.
| | - V-T T Nguyen
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA, USA
| | - S W Edmonds
- Division of General Internal Medicine, Department of Internal Medicine, College of Medicine, University of Iowa Carver, Iowa City, IA, USA
- Department of Veterans Affairs, CADRE, Iowa City VA HCS, Iowa City, IA, USA
- College of Nursing, University of Iowa, Iowa City, IA, USA
| | - Y Lou
- Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, IA, USA
| | | | - K G Saag
- Division of Clinical Immunology and Rheumatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - P Cram
- Department of Medicine, University of Toronto, Toronto, Canada
- Division of General Internal Medicine and Geriatrics, Mt. Sinai/UHN Hospitals, Toronto, Canada
| | - F D Wolinsky
- Division of General Internal Medicine, Department of Internal Medicine, College of Medicine, University of Iowa Carver, Iowa City, IA, USA
- College of Nursing, University of Iowa, Iowa City, IA, USA
- Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, IA, USA
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Majumdar SR, McAlister FA, Johnson JA, Rowe BH, Bellerose D, Hassan I, Lier DA, Li S, Maksymowych WP, Menon M, Russell AS, Wirzba B, Beaupre LA. Comparing Strategies Targeting Osteoporosis to Prevent Fractures After an Upper Extremity Fracture (C-STOP Trial): A Randomized Controlled Trial. J Bone Miner Res 2018; 33:2114-2121. [PMID: 30040140 DOI: 10.1002/jbmr.3557] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 06/11/2018] [Accepted: 06/27/2018] [Indexed: 11/12/2022]
Abstract
We compared osteoporosis care after upper extremity fragility fracture using a low-intensity Fracture Liaison Service (FLS) versus a high-intensity FLS in a pragmatic patient-level parallel-arm comparative effectiveness trial undertaken at a Canadian academic hospital. A low-intensity FLS (active-control) that identified patients and notified primary care providers was compared to a high-intensity FLS (case manager) where a specially-trained nurse identified patients, investigated bone health, and initiated appropriate treatment. A total of 361 community-dwelling participants 50 years or older with upper extremity fractures who were not on bisphosphonate treatment were included; 350 (97%) participants completed 6-month follow-up undertaken by assessors blinded to group allocation. The primary outcome was difference in bisphosphonate treatment between groups 6 months postfracture; secondary outcomes included differences in bone mineral density (BMD) testing and a predefined composite measure termed "appropriate care" (taking or making an informed decision to decline medication for those with low BMD; not taking bisphosphonate treatment for those with normal BMD). Absolute differences (%), relative risks (RR with 95% confidence intervals [CIs]), number-needed-to-treat (NNT), and direct costs were compared. A total of 181 participants were randomized to active-control and 180 to case-manager using computer-generated randomization; the groups were similar on study entry. At 6 months, 51 (28%) active-control versus 86 (48%) case-manager participants started bisphosphonate treatment (20% absolute difference; RR 1.70; 95% CI, 1.28 to 2.24; p < 0.0001; NNT = 5). Of active-controls, 108 (62%) underwent BMD testing compared to 128 (73%) case-managed patients (11% absolute difference; RR 1.17; 95% CI, 1.01 to 1.36; p = 0.03). Appropriate care was received by 76 (44%) active-controls and 133 (76%) case-managed participants (32% absolute difference; RR 1.73; 95% CI, 1.43 to 2.09; p < 0.0001). The direct cost per participant was $18 Canadian (CDN) for the active-control intervention compared to $66 CDN for the case-manager intervention. In summary, case-management led to substantially greater improvements in bisphosphonate treatment and appropriate care within 6 months of fracture than the active control. © 2018 American Society for Bone and Mineral Research.
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Affiliation(s)
- Sumit R Majumdar
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | | | - Jeffrey A Johnson
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Brian H Rowe
- Department of Emergency Medicine, University of Alberta, Edmonton, AB, Canada
| | - Debbie Bellerose
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Imran Hassan
- EPICORE Centre, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Douglas A Lier
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Stephanie Li
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | | | - Matthew Menon
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | | | - Brian Wirzba
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Lauren A Beaupre
- Department of Physical Therapy, University of Alberta, Edmonton, AB, Canada
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10
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Hall SF, Wright NC, Wolinsky FD, Lou Y, Edmonds S, Roblin D, Jones M, Saag K, Cram P. The prevalence of overtreatment of osteoporosis: results from the PAADRN trial. Arch Osteoporos 2018; 13:103. [PMID: 30267162 DOI: 10.1007/s11657-018-0517-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 09/16/2018] [Indexed: 02/03/2023]
Abstract
Overtreatment of osteoporosis increases costs and puts patients at unnecessary risk of experiencing adverse drug events. In the Patient Activation After DXA Receipt Notification (PAADRN) trial, we found that 8% of individuals with no indication for therapy were recommended a new osteoporosis medication or continuation of an existing medication. PURPOSE There is a robust body of literature addressing undertreatment in osteoporosis, but limited data addressing overtreatment. Understanding overtreatment is important to minimize harm and decrease costs. METHODS One of the pre-specified post hoc analyses of the PAADRN trial, a randomized, controlled, pragmatic clinical trial, was to quantify and identify risk factors associated with osteoporosis overtreatment. PAADRN included patients ≥ 50 years of age presenting for bone density testing between February, 2012, and August, 2014, at three US healthcare systems. We assessed 20,397 patients for eligibility and randomized 7749. Intervention patients received a tailored letter containing their dual-energy X-ray absorptiometry (DXA) results and an educational osteoporosis brochure. Control patients received usual care. Using the National Osteoporosis Foundation treatment guidelines, we defined overtreatment as the receipt of osteoporosis pharmacotherapy 12 weeks after DXA when treatment was not indicated. We evaluated the relationship between the following baseline variables-sex, race/ethnicity, educational attainment, and differences across health systems-and overtreatment using a series of multivariable logistic regression models. RESULTS Among 3602 patients with no apparent indication for osteoporosis treatment, 292 (8.1%; 95% CI, 7.22 to 9.00%) received a new prescription for osteoporosis pharmacotherapy or were instructed to continue an existing medication (presumed overtreatment). Presumed overtreatment was more common among participants with prior DXA history, those who reported a history of osteoporosis or low bone mass, and those referred for testing by family medicine providers. CONCLUSION In our sample of older adults, overuse of osteoporosis pharmacotherapy was only 8.1%. Nevertheless, overtreatment exposes patients to possible risk with negligible chance of benefit and should be minimized. TRIAL REGISTRATION clinicaltrials.gov identifier: NCT01507662.
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Affiliation(s)
- Sylvie F Hall
- Department of Pharmacy, Cleveland Clinic, 9500 Euclid Ave JJN1-200, Cleveland, OH, 44195, USA.
| | - Nicole C Wright
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Fredric D Wolinsky
- Division of General Internal Medicine, Department of Internal Medicine, College of Medicine, University of Iowa Carver, Iowa City, IA, USA
- Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, IA, USA
- College of Nursing, University of Iowa, Iowa City, IA, USA
| | - Yiyue Lou
- Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, IA, USA
| | - Stephanie Edmonds
- Division of General Internal Medicine, Department of Internal Medicine, College of Medicine, University of Iowa Carver, Iowa City, IA, USA
- College of Nursing, University of Iowa, Iowa City, IA, USA
| | - Douglas Roblin
- Kaiser Permanente, Atlanta, GA, USA
- School of Public Health, Georgia State University, Atlanta, GA, USA
| | - Michael Jones
- Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, IA, USA
| | - Kenneth Saag
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Peter Cram
- Faculty of Medicine, University of Toronto, Toronto, Canada
- Division of General Internal Medicine and Geriatrics, Mt. Sinai and UHN Hospitals, Toronto, Canada
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Nayak S, Greenspan SL. How Can We Improve Osteoporosis Care? A Systematic Review and Meta-Analysis of the Efficacy of Quality Improvement Strategies for Osteoporosis. J Bone Miner Res 2018; 33:1585-1594. [PMID: 29637658 PMCID: PMC6129396 DOI: 10.1002/jbmr.3437] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 03/20/2018] [Accepted: 04/01/2018] [Indexed: 12/13/2022]
Abstract
Although osteoporosis affects 10 million people in the United States, screening and treatment rates remain low. We performed a systematic review and meta-analysis of the efficacy of quality improvement strategies to improve osteoporosis screening (bone mineral density [BMD]/dual-energy X-ray absorptiometry [DXA] testing) and/or treatment (pharmacotherapy) initiation rates. We developed broad literature search strategies for PubMed, Embase, and Cochrane Library databases, and applied inclusion/exclusion criteria to select relevant studies. Random-effects meta-analyses were performed for outcomes of BMD/DXA testing and/or osteoporosis treatment. Forty-three randomized clinical studies met inclusion criteria. For increasing BMD/DXA testing in patients with recent or prior fracture, meta-analyses demonstrated several efficacious strategies, including orthopedic surgeon or fracture clinic initiation of osteoporosis evaluation or management (risk difference 44%, 95% confidence interval [CI] 26%-63%), fracture liaison service/case management (risk difference 43%, 95% CI 23%-64%), multifaceted interventions targeting providers and patients (risk difference 24%, 95% CI 15%-32%), and patient education and/or activation (risk difference 16%, 95% CI 6%-26%). For increasing osteoporosis treatment in patients with recent or prior fracture, meta-analyses demonstrated significant efficacy for interventions of fracture liaison service/case management (risk difference 20%, 95% CI 1%-40%) and multifaceted interventions targeting providers and patients (risk difference 12%, 95% CI 6%-17%). The only quality improvement strategy for which meta-analysis findings demonstrated significant improvement of osteoporosis care for patient populations including individuals without prior fracture was patient self-scheduling of DXA plus education, for increasing the outcome of BMD testing (risk difference 13%, 95% CI 7%-18%). The meta-analyses findings were limited by small number of studies in each analysis; high between-study heterogeneity; sensitivity to removal of individual studies; and unclear risk of bias of included studies. Despite the limitations of the current body of evidence, our findings indicate there are several strategies that appear worthwhile to enact to try to improve osteoporosis screening and/or treatment rates. © 2018 American Society for Bone and Mineral Research.
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12
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Danila MI, Outman RC, Rahn EJ, Mudano AS, Redden DT, Li P, Allison JJ, Anderson FA, Wyman A, Greenspan SL, LaCroix AZ, Nieves JW, Silverman SL, Siris ES, Watts NB, Miller MJ, Curtis JR, Warriner AH, Wright NC, Saag KG. Evaluation of a Multimodal, Direct-to-Patient Educational Intervention Targeting Barriers to Osteoporosis Care: A Randomized Clinical Trial. J Bone Miner Res 2018; 33:763-772. [PMID: 29377378 PMCID: PMC6016546 DOI: 10.1002/jbmr.3395] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 12/14/2017] [Accepted: 01/10/2018] [Indexed: 11/06/2022]
Abstract
Osteoporosis treatment rates are declining, even among those with past fractures. Novel, low-cost approaches are needed to improve osteoporosis care. We conducted a parallel group, controlled, randomized clinical trial evaluating a behavioral intervention for improving osteoporosis medication use. A total of 2684 women with self-reported fracture history after age 45 years not using osteoporosis therapy from US Global Longitudinal Study of Osteoporosis in Women (GLOW) sites were randomized 1:1 to receive a multimodal, tailored, direct-to-patient, video intervention versus usual care. The primary study outcome was self-report of osteoporosis medication use at 6 months. Other outcomes included calcium and vitamin D supplementation, bone mineral density (BMD) testing, readiness for behavioral change, and barriers to treatment. In intent-to-treat analyses, there were no significant differences between groups (intervention versus control) in osteoporosis medication use (11.7% versus 11.4%, p = 0.8), calcium supplementation (31.8% versus 32.6%, p = 0.7), vitamin D intake (41.3% versus 41.9%, p = 0.8), or BMD testing (61.8% versus 57.1%, p = 0.2). In the intervention group, fewer women were in the precontemplative stage of behavior change, more women reported seeing their primary care provider, had concerns regarding osteonecrosis of the jaw, and difficulty in taking/remembering to take osteoporosis medications. We found differences in BMD testing among the subgroup of women with no prior osteoporosis treatment, those who provided contact information, and those with no past BMD testing. In per protocol analyses, women with appreciable exposure to the online intervention (n = 257) were more likely to start nonbisphosphonates (odds ratio [OR] = 2.70; 95% confidence interval [CI] 1.26-5.79) compared with the usual care group. Although our intervention did not increase the use of osteoporosis therapy at 6 months, it increased nonbisphosphonate medication use and BMD testing in select subgroups, shifted participants' readiness for behavior change, and altered perceptions of barriers to osteoporosis treatment. Achieving changes in osteoporosis care using patient activation approaches alone is challenging. © 2018 American Society for Bone and Mineral Research.
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Affiliation(s)
- Maria I Danila
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ryan C Outman
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Amy S Mudano
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - David T Redden
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - Peng Li
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Fred A Anderson
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Allison Wyman
- University of Massachusetts Medical School, Worcester, MA, USA
| | | | - Andrea Z LaCroix
- Group Health Cooperative, Seattle, WA, USA.,University of California San Diego, La Jolla, CA, USA
| | | | | | - Ethel S Siris
- Columbia University Medical Center, New York, NY, USA
| | - Nelson B Watts
- Mercy Health Osteoporosis and Bone Health Services, Cincinnati, OH, USA
| | - Michael J Miller
- Department of Pharmaceutical Sciences, Irma Lerma Rangel College of Pharmacy, Texas A&M University, College Station, TX, USA
| | | | - Amy H Warriner
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Kenneth G Saag
- University of Alabama at Birmingham, Birmingham, AL, USA
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13
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Roblin DW, Cram P, Lou Y, Edmonds SW, Hall SF, Jones MP, Saag KG, Wright NC, Wolinsky FD. Diet and exercise changes following bone densitometry in the Patient Activation After DXA Result Notification (PAADRN) study. Arch Osteoporos 2018; 13:4. [PMID: 29307094 PMCID: PMC7409367 DOI: 10.1007/s11657-017-0402-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 11/13/2017] [Indexed: 02/03/2023]
Abstract
UNLABELLED Calcium and vitamin D intake and exercise are suboptimal among older adults. Following bone densitometry, a letter communicating individualized fracture risk accompanied by an educational brochure improved participants' lifestyle-but no more than existing communication strategies-over 52 weeks. Simple communication strategies are insufficient for achieving optimal levels of bone health behaviors. PURPOSE The Patient Activation After DXA Result Notification (PAADRN) study was designed to evaluate whether a letter with individualized fracture risk and an educational brochure mailed to patients soon after their DXA might improve bone health behaviors (daily calcium intake, vitamin D supplementation, and weekly exercise sessions) compared to slower, less individualized communication characterizing usual care. METHODS Participants ≥ 50 years were recruited, at three sites, following their DXA and randomized with 1:1 allocation to intervention and control (usual care only) groups. Data were collected at enrollment interview and by phone survey at 12 and 52 weeks thereafter. Intention-to-treat analyses were conducted on 7749 of the 20,397 eligible participants who enrolled. Changes in bone health behaviors were compared within and between study groups. Average treatment effects and heterogeneity of treatment effects were estimated with multivariable linear and logistic regression models. RESULTS In unadjusted analyses, calcium intake, vitamin D supplementation, and weekly exercise sessions increased significantly over 52 weeks within both the intervention and control groups (all p < 0.001). In unadjusted analyses and multivariable models, increases in each behavior did not significantly differ between the intervention and control groups. Intervention group participants with a > 20% 10-year fracture risk at enrollment did, however, have a significantly greater increase in calcium intake compared to other study participants (p = 0.031). CONCLUSIONS Bone health behaviors improved, on average, over 52 weeks among all participants following a DXA. Receipt of the PAADRN letter and educational brochure did not directly improve bone health behaviors compared to usual care. TRIAL REGISTRATION The Patient Activation after DXA Result Notification (PAADRN) Study is registered at ClinicalTrials.Gov: NCT01507662, https://clinicaltrials.gov/ct2/show/NCT01507662.
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Affiliation(s)
- Douglas W. Roblin
- Mid-Atlantic Permanente Research Institute, 2101 East Jefferson St., 3 West, Rockville, MD 20852, USA,Center for Clinical and Outcomes Research, Kaiser Permanente, Atlanta, GA, USA
| | - Peter Cram
- Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA,Faculty of Medicine, University of Toronto, Toronto, Canada,Division of General Internal Medicine and Geriatrics, Mt. Sinai/UHN Hospitals, Toronto, Canada
| | - Yiyue Lou
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, IA, USA
| | - Stephanie W. Edmonds
- Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA,College of Nursing, University of Iowa, Iowa City, IA, USA
| | - Sylvie F. Hall
- College of Nursing, University of Iowa, Iowa City, IA, USA
| | - Michael P. Jones
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, IA, USA
| | - Kenneth G. Saag
- Division of Clinical Immunology and Rheumatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Nicole C. Wright
- Division of Clinical Immunology and Rheumatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA,Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Fredric D. Wolinsky
- Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA,College of Nursing, University of Iowa, Iowa City, IA, USA,Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, IA, USA
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14
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Caplan L, Hansen KE, Saag KG. Response to the American College of Physicians Osteoporosis Guideline, 2017 Update. Arthritis Rheumatol 2017; 69:2097-2101. [PMID: 28881479 DOI: 10.1002/art.40305] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 08/25/2017] [Indexed: 01/07/2023]
Affiliation(s)
- Liron Caplan
- University of Colorado Denver School of Medicine and Denver Veterans Affairs Medical Center, Denver, Colorado
| | - Karen E Hansen
- University of Wisconsin School of Medicine & Public Health, Madison
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15
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Wolinsky FD, Hall SF, Lou Y, Edmonds SW, Saag KG, Roblin DW, Wright NC, Jones MP, Cram P, Curtis JR, Morgan SL, Schlechte JA, Williams JH, Zelman DJ. The cost of a patient activation intervention for achieving successful outcomes: results from the PAADRN randomized controlled trial. Osteoporos Int 2017. [PMID: 28620779 PMCID: PMC5670012 DOI: 10.1007/s00198-017-4113-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
UNLABELLED In a large, pragmatic clinical trial, we calculated the costs of achieving four successful patient-centered outcomes using a tailored patient activation DXA result letter accompanied by a bone health brochure. The cost to achieve one successful outcome (e.g., a 0.5 standard deviation improvement in care satisfaction) ranged from $127.41 to $222.75. INTRODUCTION Pragmatic randomized controlled trials (RCTs) should focus on patient-centered outcomes and report the costs for achieving those outcomes. We calculated per person incremental intervention costs, the number-needed-to-treat (NNT), and incremental per patient costs (cost per NNT) for four patient-centered outcomes in a direct-to-patient bone healthcare intervention. METHODS The Patient Activation after DXA Result Notification (PAADRN) pragmatic RCT enrolled 7749 patients presenting for DXA at three health centers between February 2012 and August 2014. Interviews occurred at baseline and 52 weeks post-DXA. Intervention subjects received an individually tailored DXA result letter accompanied by an educational bone health brochure 4 weeks post-DXA, while the usual care subjects did not. Outcomes focused on patients (a) correctly identifying their results, (b) contacting their providers, (c) discussing their results with their providers, and (d) satisfaction with their bone healthcare. NNTs were determined using intention-to-treat linear probability models, per person incremental intervention costs were calculated, and costs per NNT were computed. RESULTS Mean age was 66.6 years old, 83.8% were women, and 75.3% were non-Hispanic whites. The incremental per patient cost (costs per NNT) to increase the ability of a patient to (a) correctly identify their DXA result was $171.07; (b) contact their provider about their DXA result was $222.75; (c) discuss their DXA result with their provider was $193.55; and (d) achieve a 0.5 SD improvement in satisfaction with their bone healthcare was $127.41. CONCLUSION An individually tailored DXA result letter accompanied by an educational brochure can improve four patient-centered outcomes at a modest cost. TRIAL REGISTRATION clinicaltrials.gov identifier NCT01507662.
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Affiliation(s)
- F D Wolinsky
- Department of Health Management and Policy, University of Iowa, 145 North Riverside Drive, CPHB N211, Iowa City, IA, 52242, USA.
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA.
- College of Nursing, University of Iowa, Iowa City, IA, USA.
| | - S F Hall
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
| | - Y Lou
- Department of Biostatistics, University of Iowa, Iowa City, IA, USA
| | - S W Edmonds
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
- College of Nursing, University of Iowa, Iowa City, IA, USA
- CADRE, Iowa City VA Healthcare System, Iowa City, IA, USA
| | - K G Saag
- Department of Internal Medicine, University of Alabama, Birmingham, AL, USA
| | - D W Roblin
- Kaiser Permanente, Atlanta, GA, USA
- Department of Health Management and Policy, Georgia State University, Atlanta, GA, USA
| | - N C Wright
- Department of Internal Medicine, University of Alabama, Birmingham, AL, USA
- Department of Epidemiology, University of Alabama, Birmingham, AL, USA
| | - M P Jones
- Department of Biostatistics, University of Iowa, Iowa City, IA, USA
| | - P Cram
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
- Department of Medicine, University of Toronto, Toronto, Canada
- Division of General Internal Medicine and Geriatrics, Mt. Sinai/UHN Hospitals, Toronto, Canada
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16
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Wolinsky FD, Lou Y, Edmonds SW, Hall SF, Jones MP, Wright NC, Saag KG, Cram P, Roblin DW. Activating Patients With a Tailored Bone Density Test Results Letter and Educational Brochure: the PAADRN Randomized Controlled Trial. J Clin Densitom 2017; 20:464-471. [PMID: 27647261 PMCID: PMC5354993 DOI: 10.1016/j.jocd.2016.08.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 08/23/2016] [Indexed: 11/25/2022]
Abstract
In cross-sectional studies, patient activation has been associated with better health behaviors, health outcomes, and health-care experiences. Moreover, tailored interventions have led to clinically meaningful improvements in patient activation, as well as health outcomes over time. We tested whether a tailored patient-activation letter communicating bone mineral density (BMD) test results plus an educational brochure improved patient activation scores and levels at 12 and 52 wk post-baseline as the mechanism leading to enhanced bone healthcare. In a randomized, controlled, double-blinded, multicenter pragmatic clinical trial, we randomized 7749 patients ≥50 yr old and presenting for BMD testing at 3 medical centers in the United States between February 2012 and August 2014. The outcome measures were patient activation scores and levels based on 6 items taken from the Patient Activation Measure (PAM) that were administered at the baseline, 12-wk, and 52-wk follow-up interviews. Mean age was 66.6 yr, 83.8% were women, and 75.3% were Non-Hispanic-Whites. Overall, PAM activation scores improved from 58.1 at baseline to 76.4 by 12 wk (p < 0.001) and to 77.2 (p = 0.002) by 52 wk post-baseline. These improvements, however, were not significantly different between the intervention and usual care groups (18.7 vs 18.1, p = 0.176, at 12 wk) in intention-to-treat analyses. PAM activation scores and levels substantially improved at 12 wk and 52 wk, but no differences were observed in these improvements between the intervention and usual care groups. These null findings may have occurred because the tailoring focused on the patient's BMD and fracture risk results, rather than on the patient's BMD and fracture risk results as well as the patient's baseline PAM activation scores or levels.
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Affiliation(s)
- Fredric D Wolinsky
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, IA, USA; Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA; University of Iowa College of Nursing, Iowa City, IA, USA.
| | - Yiyue Lou
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, IA, USA
| | - Stephanie W Edmonds
- Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA; University of Iowa College of Nursing, Iowa City, IA, USA
| | - Sylvie F Hall
- Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Michael P Jones
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, IA, USA
| | - Nicole C Wright
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA; Division of Clinical Immunology and Rheumatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kenneth G Saag
- Division of Clinical Immunology and Rheumatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Peter Cram
- Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA; Department of Medicine, University of Toronto, Toronto, Canada; Division of General Internal Medicine, Mt. Sinai/UHN Hospitals, Toronto, Canada
| | - Douglas W Roblin
- Kaiser Permanente of Georgia, Atlanta, GA, USA; School of Public Health, Georgia State University, Atlanta, GA, USA
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17
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Wolinsky FD, Lou Y, Edmonds SW, Saag KG, Roblin DW, Wright NC, Jones MP, Cram P. The effects of a patient activation intervention on smoking and excessive drinking cessations: results from the PAADRN randomized controlled trial. Osteoporos Int 2017; 28:3055-3060. [PMID: 28573377 PMCID: PMC5670005 DOI: 10.1007/s00198-017-4101-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 05/21/2017] [Indexed: 11/28/2022]
Abstract
UNLABELLED Patients may exhibit risky bone health behaviors. In a large pragmatic clinical trial, we tested whether a tailored patient activation DXA result letter accompanied by a bone health brochure led to smoking and excessive drinking cessations. The intervention did not, however, alter these risky bone health behaviors. INTRODUCTION Besides dual-energy x-ray absorptiometry (DXA) screening and pharmacotherapy when indicated, beneficial bone health behaviors including proper calcium and vitamin D intake and weight-bearing and muscle-strengthening exercise should be encouraged. Similarly, risky bone health behaviors like smoking and excessive drinking should be discouraged. We examined whether a direct-to-patient activation intervention led to smoking and excessive drinking cessations. METHODS The Patient Activation after DXA Result Notification (PAADRN) pragmatic clinical trial enrolled 7749 patients between February 2012 and August 2014. Interviews occurred at baseline and 12 and 52 weeks later. Intervention subjects were mailed an individually tailored DXA results letter accompanied by a bone health educational brochure 4 weeks post-DXA. Usual care subjects were not sent these materials. Smoking and excessive drinking were assessed by self-report at each interview. Intention-to-treat linear probability models were used. RESULTS Mean age was 66.6 years, 83.8% were women, and 75.3% were Non-Hispanic-Whites. Smoking was reported at baseline by 7.6% of the intervention group vs. 7.7% of the usual care group (p = 0.873). Excessive drinking was reported at baseline by 6.5% of the intervention group vs. 6.5% of the usual care group (p = 0.968). Intention-to-treat analyses indicated no significant differences between the intervention vs. usual care groups at either 12 or 52 weeks post-DXA (all p values ≥ 0.346). CONCLUSION An individually tailored DXA result letter accompanied by an educational brochure did not lead to smoking or excessive drinking cessations in patients who received DXA. TRIAL REGISTRATION clinicaltrials.gov identifier NCT01507662.
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Affiliation(s)
- F D Wolinsky
- Department of Health Management and Policy, University of Iowa, 145 North Riverside Drive, CPHB N211, Iowa City, Iowa City, IA, 52242, USA.
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA.
- College of Nursing, University of Iowa, Iowa City, IA, USA.
| | - Y Lou
- Department of Biostatistics, University of Iowa, Iowa City, IA, USA
| | - S W Edmonds
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
- College of Nursing, University of Iowa, Iowa City, IA, USA
- CADRE, Iowa City VA Healthcare System, Iowa City, IA, USA
| | - K G Saag
- Department of Internal Medicine, University of Alabama, Birmingham, AL, USA
| | - D W Roblin
- Kaiser Permanente, Atlanta, GA, USA
- Department of Health Management and Policy, Georgia State University, Atlanta, GA, USA
| | - N C Wright
- Department of Internal Medicine, University of Alabama, Birmingham, AL, USA
- Department of Epidemiology, University of Alabama, Birmingham, AL, USA
| | - M P Jones
- Department of Biostatistics, University of Iowa, Iowa City, IA, USA
| | - P Cram
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
- Department of Medicine, University of Toronto, Toronto, Canada
- Division of General Internal Medicine and Geriatrics, Mt. Sinai/UHN Hospitals, Toronto, Canada
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18
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McKenna MJ. Activating Patients. J Clin Densitom 2017; 20:460-461. [PMID: 27876205 DOI: 10.1016/j.jocd.2016.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 10/20/2016] [Indexed: 11/24/2022]
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Roblin DW, Zelman D, Plummer S, Robinson BE, Lou Y, Edmonds SW, Wolinsky FD, Saag KG, Cram P. Evaluation of a "Just-in-Time" Nurse Consultation on Bone Health: A Pilot Randomized Controlled Trial. Perm J 2017; 21:16-112. [PMID: 28746019 DOI: 10.7812/tpp/16-112] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
CONTEXT Evidence is inconclusive whether a nurse consultation can improve osteoporosis-related patient outcomes. OBJECTIVE To evaluate whether a nurse consultation immediately after dual-energy x-ray absorptiometry (DXA) produced better osteoporosis-related outcomes than a simple intervention to activate adults in good bone health practices or usual care. DESIGN Pilot randomized controlled trial, conducted within the larger Patient Activation After DXA Result Notification (PAADRN) trial (NCT01507662). After DXA, consenting adults age 50 years or older were randomly assigned to 3 groups: nurse consultation, PAADRN intervention (mailed letter with individualized fracture risk and an educational brochure), or usual care (control). Nurse consultation included reviewing DXA results, counseling on bone health, and ordering needed follow-up tests or physician referrals. MAIN OUTCOME MEASURES Change from baseline to 52 weeks in participant-reported osteoporosis-related pharmacotherapy, lifestyle, activation and self-efficacy, and osteoporosis care satisfaction. RESULTS Nurse consultation participants (n = 104) reported 52-week improvements in strengthening and weight-bearing exercise (p = 0.09), calcium intake (p < 0.01), osteoporosis knowledge (p = 0.04), activation (p < 0.01), dietary self-efficacy (p = 0.06), and osteoporosis care satisfaction (p < 0.01). Compared with PAADRN intervention participants (n = 39), nurse consultation participants had improved dietary self-efficacy (p = 0.07) and osteoporosis care satisfaction (p = 0.05). No significant improvements in osteoporosis-related outcomes were achieved vs PAADRN controls (n = 70). CONCLUSION "Just-in-time" nurse consultation yielded a few improvements over 52 weeks in osteoporosis-related outcomes; however, most changes were not different from those obtained through the lower-cost PAADRN intervention or usual care.
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Affiliation(s)
- Douglas W Roblin
- Professor of Health Management and Policy at Georgia State University School of Public Health and a Consulting Senior Research Scientist at the Center for Clinical and Outcomes Research in Atlanta.
| | - David Zelman
- At the time of this study was a Rheumatologist with The Southeast Permanente Medical Group, Inc, in Atlanta, GA.
| | - Sally Plummer
- At the time of this study was a Consulting Nurse Educator at the Center for Clinical and Outcomes Research in Atlanta, GA.
| | - Brandi E Robinson
- Senior Project Manager at the Center for Clinical and Outcomes Research in Atlanta, GA.
| | - Yiyue Lou
- Biostatistician in the College of Public Health at the University of Iowa in Iowa City.
| | - Stephanie W Edmonds
- Graduate Research Assistant in Internal Medicine and a Doctoral Candidate in the College of Nursing at the University of Iowa in Iowa City.
| | - Fredric D Wolinsky
- The John W Colloton Chair in the College of Public Health at the University of Iowa in Iowa City.
| | - Kenneth G Saag
- Professor of Medicine in the Division of Clinical Immunology and Rheumatology at the University of Alabama at Birmingham.
| | - Peter Cram
- Professor of Internal Medicine in the Division of General Internal Medicine at the University of Toronto and the Director of General Internal Medicine at the University Health Network and Mount Sinai Hospital in Ontario, Canada.
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Hall SF, Edmonds SW, Lou Y, Cram P, Roblin DW, Saag KG, Wright NC, Jones MP, Wolinsky FD. Patient-reported reasons for nonadherence to recommended osteoporosis pharmacotherapy. J Am Pharm Assoc (2003) 2017; 57:503-509. [PMID: 28602783 PMCID: PMC5515491 DOI: 10.1016/j.japh.2017.05.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Revised: 04/27/2017] [Accepted: 05/03/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVES As many as one-half of patients recommended for osteoporosis pharmacotherapy do not take their medications. To identify intervention targets, we examined patient characteristics associated with nonadherence to recommended pharmacotherapy and their reasons for nonadherence. METHODS Data come from the Patient Activation after DXA Result Notification (PAADRN) study, a randomized controlled trial of 7749 patients aged 50 years or older presenting for dual-energy X-ray absorptiometry (DXA) at 3 health centers in the United States. We focused on the 790 patients who reported receiving a recommendation for new pharmacotherapy at baseline. Using Pearson chi-squared tests for categorical variables, 2-sample t tests for continuous variables, and multivariable multinomial logistic regression, we compared those who reported starting the recommended medication (adherers) with temporary nonadherers and nonadherers on demographics, health habits, DXA impression, 10-year probability of fracture using the assessment tool, and osteoporosis knowledge, and we examined their stated reasons for nonadherence. RESULTS Mean age was 66.8 years (SD = 8.9); 87.2% were women, and 84.2% were white. One-fourth of patients (24.8%) reported that they did not start their recommended pharmacotherapy. In the unadjusted analyses, the only factor significantly associated with nonadherence was osteoporosis knowledge, with those having better knowledge being less likely to take their medications (P < 0.05). The most common reasons for nonadherence were fear of adverse effects (53.3%), a dislike of taking medicine (25.3%), and the belief that the medication would not help their condition (16.7%). CONCLUSION One in 4 patients recommended for osteoporosis pharmacotherapy declined treatment because they feared potential adverse effects, did not like taking medicine, or believed that the medication would not help their condition. Improved patient counseling on the potential adverse effects of osteoporosis treatment and the risk-benefit ratio for these medications may increase adherence.
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Cram P, Saag KG, Lou Y, Edmonds SW, Hall SF, Roblin DW, Wright NC, Jones MP, Wolinsky FD. Racial Differences and Disparities in Osteoporosis-related Bone Health: Results From the PAADRN Randomized Controlled Trial. Med Care 2017; 55:561-568. [PMID: 28288074 PMCID: PMC5432397 DOI: 10.1097/mlr.0000000000000718] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Determining whether observed differences in health care can be called disparities requires persistence of differences after adjustment for relevant patient, provider, and health system factors. We examined whether providing dual-energy x-ray absorptiometry (DXA) test results directly to patients might reduce or eliminate racial differences in osteoporosis-related health care. DESIGN, SUBJECTS, AND MEASURES We analyzed data from 3484 white and 1041 black women who underwent DXA testing at 2 health systems participating in the Patient Activation after DXA Result Notification (PAADRN) pragmatic clinical trial (ClinicalTrials.gov NCT-01507662) between February 2012 and August 2014. We examined 7 outcomes related to bone health at 12 weeks and 52 weeks post-DXA: (1) whether the patient correctly identified their DXA baseline results; (2) whether the patient was on guideline-concordant osteoporosis pharmacotherapy; (3) osteoporosis-related satisfaction; (4) osteoporosis knowledge; (5 and 6) osteoporosis self-efficacy for exercise and for diet; and (7) patient activation. We examined whether unadjusted differences in outcomes between whites and blacks persisted after adjusting for patient, provider, and health system factors. RESULTS Mean age was 66.5 years and 29% were black. At baseline black women had less education, poorer health status, and were less likely to report a history of osteoporosis (P<0.001 for all). In unadjusted analyses black women were less likely to correctly identify their actual DXA results, more likely to be on guideline-concordant therapy, and had similar patient activation. After adjustment for patient demographics, baseline health status and other factors, black women were still less likely to know their actual DXA result and less likely to be on guideline-concordant therapy, but black women had greater patient activation. CONCLUSIONS Adjustment for patient and provider level factors can change how racial differences are viewed, unmasking new disparities, and providing explanations for others.
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Affiliation(s)
- Peter Cram
- Department of Medicine, University of Toronto, Toronto, Canada
- Division of General Internal Medicine and Geriatrics, Mt. Sinai/UHN Hospitals, Toronto, Canada
- Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Kenneth G. Saag
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL
| | - Yiyue Lou
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, IA
| | - Stephanie W. Edmonds
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, IA
- University of Iowa College of Nursing, Iowa City, IA
- CADRE, Iowa City VA Healthcare System, Iowa City, IA
| | - Sylvie F. Hall
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, IA
| | - Douglas W. Roblin
- Kaiser Permanente, Atlanta, GA
- School of Public Health, Georgia State University, Atlanta, GA
| | - Nicole C. Wright
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL
| | - Michael P. Jones
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, IA
| | - Fredric D. Wolinsky
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, IA
- University of Iowa College of Nursing, Iowa City, IA
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